
<%@page contentType="text/html" pageEncoding="UTF-8"%>
<!DOCTYPE html>
<html>
    <head>
         <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <link rel="stylesheet" type="text/css" href="css/kipmol.css">
        <title>KIPEM Online </title>
    </head>
    <body> 
        <div id="main">
            <div id="header">
               
                <a href="#">
                    <img src="img/Logo_surabaya.gif" id="logo">
                </a>
                <img src="img/kipem.jpg" id="logoText" alt="kipmol">
            </div>
                
            </div>
       <div id="fullpage">
            <div id="welcomeText">
                <p>Perpanjangan KIPEM</p></div>
                <form id="form1" name="form1" method="post" action="">
            
  <p>NO KIPEM : 
    <label for="nokipem"></label>
  <input type="text" name="nokipem" id="nokipem" />
  </p>
  <p>Masa Berlaku Sampai :
    <label for="masaberlaku'"></label>
    <input type="text" name="masaberlaku'" id="masaberlaku'" />
  </p>
  <p>
    <input type="submit" name="submit" id="submit" value="Submit" />
  </p>
</form>
       </div>   
    </body>
</html>